he has to lead this you guys. -- has totally dissed you guys. just to give you an idea of what i am talking about since most of you are americans and greedy american news, i guess after 9/11 tony blair, sorry, i guess he had his bad points, but he was very good on the war on terrorism. when obama comes in he said you can't have it back now. -- can have it back now. obama said no thanks. th morafah that made pretty big news or rattner @ reported a all here. here.

. . gordon brown's wife brought lovely gifts for the obama girls. they gave him dvd's of his own speeches. maybe we should try that with kim jong il. here are my greatest hits. he does not acknowledge a special relationship, why should you? it looks like that is it. thank you, young republicans, you are very well dressed.

>> "washington journal" continues. continues. host: senator ben cardin from maryland, our final guest today. your photograph is all over the papers this morning. we will show "will call" first -- we are having a hard time with the camera -- you are standing with jack reed and max baucus, and in both cases, everyone is smiling. what is going on in that room? guest: it is the day before recess, so that maybe while we -- why we are smiling. we are talking about health care reform. we are making a lot of progress. americans are starting to understand that the status quo is unacceptable. the cost of health care is rising and people are losing their benefits. in maryland, it costs about

$11,000 for a family plan, private insurance. that is scheduled to increase in the next 10 years, projected to be $23,000. every day in maryland, a couple of people lose their health insurance. americans are rightly concerned that we get it right. we were talking about how to inform our constituents over august about what is in health care reform. host: what are the aspects of it that are so important to you, the costs of getting it right? guest: preserving the individual's right to maintain health insurance, predictability that what it will be there in the future. we cannot allow continued escalation of health care expenses as it is going today. providing protection for hot -- for private insurance. making sure that companies cannot underwrite or be discriminating against you

because of pre-existing conditions, that they need to cover the wellness programs, so that they are affordable. these types of protections need to be in insurance reform. host: how should it be financed? guest: that is a great question. ultimately, it needs to bring down the cost of health care. but you need to invest to get that done. the largest part of paying for it is within the health-care system itself, by bringing down costs, getting rid of allab tess that are not needed, those types of things to bring the system more cost-effective. the second way is to try to look at ways that we can pay for it in the short term, provide the long-term financial stability of the system. host: headline in "the wall street journal," " sen. enzi

want to rush into health care deal." how important is bipartisanship? guest: i think it is very important. we will have a better bill if democrats and republicans work together. this is not a partisan problem. it's a problem our nation confronts. i hope we have a bipartisan bill at the end of the day. host: i would like to talk about the long-term costs. the cbo scoring on this became quite an issue. "wall street journal" editorial- page. it talks about what happens after the 10-year telescope that the cbo booked at. because there is a lot of discussion as you go home about this, i want to have to address this. "the congressional budget office estimates that the house bill increases the deficit by 239 billon dollars over the next decade.

the under reported news is the new spending that will continue to increase beyond the 10-year period that cbo examines, and that this lot will overwhelm even the house democrats to tax increases." guest: we will not pass a bill in the united states senate that does not bring down the cost of health care in this country. we want to bend the cost curve to bring down the costs and make sure that it does not add to the deficit. we are committed to making sure israel. in the short -- making short it is real. american families will not be paying as much as they are paying today for their healthcare needs. host: how important to you is a public option? guest: a public option is imported to bring down costs. we want to strengthen private insurance and strengthen protections for private insurance, and for those who cannot find private insurance,

the public insurance option is important, and it allows us to have a barometer to make sure we can keep costs down. host: california is on the line, democrats line. caller: thank you for taking my call. i have a couple of points and then the question or two. host: will you keep it brief? caller: i will. what are you going to do to try to curb the disruptive mob-type incursions that are happening at the town hall meetings? it seems like the methods will be lost in the shuffle with all the disruptive behavior going on. the next thing is, as far as health care reform is concerned, we desperately needed this. my personal views are that unless we have universal health care, i do not think that on a

global basis we will ever be able to compete with other countries in the marketplace. however, that is not practical, it will not happen, i realize this. but a public option or some type of health insurance exchange is desperately needed. health reform is needed. host: how about that question, please? caller: will you please do what we sent you guys to washington to do and not allow the private interests to sway you to the point of diluting this bill where returns are to be not the format we need? please, i am begging you. thank you very much. have a great day. guest: i think most members of the united states senate and congress believe that this is our moment to correct the health care system of this country. we know it will not be easy. we know that there are a lot of special interests out there that have a vested interests. but this is such an important issue that we want to get it right. we want to use the break to get

information out to people of our states. we want them to understand what is in the bill. we are not trying to persuade them that we should do it this way or that way. we want everyone operating under the same set of facts. if we do nothing, then we do know one thing -- health care costs will continue to consume a greater percentage of our economy, more people will be without health insurance, entering our health care system in a more expensive way, the hidden tax we all pay for those in my state, $11,000 a year, will continue to grow. those who have insurance pay $11,000 extra for those who do not. those costs will continue to grow. we want to get this right. it is not an easy issue to deal with. we want to make sure that people understand what is in the bill. we want to make sure the people have a right to continue the private coverage and nature is affordable in the future. host: how about her comment about the protests at the

meetings? guest: we expect that. this is a democracy and people have the right to be heard. we hope people are respectful and allow other people to be heard as well. i expect to listen to marylanders during the recess i hope people listen so that they can get the facts. the purpose of a town hall meeting is to have an exchange of views, not to have someone to monopolize it. host: the local "examiner" newspaper this morning says that you have a town hall that is invitation only. guest: that is not true. it is open to the public. that is some reporter trying to make a story where none existed. host: who will be with you? guest: myself. i will have some people with the university, but it is an opportunity to top -- to talk to people. host: 4 senator ben cardin,

lafayette, indiana, bonnie, republican line. caller: hello, senator cardin. i question is why cann't the health care system we have now have reform and regulations? the government cannot seem to manage medicare and medicaid. what i am asking is why they cannot do it with a reform and regulations? guest: i personally believe that medicare has been a great success. but it has covered our seniors and those with disabilities with comprehensive -- it could be stronger. as far as benefits that are covered, our seniors have the highest costs but they are the only ones guaranteed coverage. they have a choice. they can choose their own doctor or hospital. they have a choice between private insurance or public

insurance. you can use medicare advantage. you can supplement it through private insurance. i think the medicare system is working well. the administrative costs are the lowest of any payers of health care in this country. i think that we benefit by >> join us later tonight for his health care town hall meeting. this took place last night. and now eunice kennedy shriver, who died today after being hospitalized recently near her home at cape cod. she was 88. we spoke with a reporter about her earlier today. >> we are joined by michael crichton -- crittenden.

>> the abuse of products put out there, the mortgage loans, eye are loans, these will flood the system and people get very excited. credit was extended to people who could not afford it. they want to address some of these problems at the root of the financial crisis. >> why is this agency necessary as a stand-alone? >> what we have seen for years is regulation for consumer protection, shared by the various federal entities. they are also responsible for the safety and soundness of the institutions. what we have seen is that the regulators post -- focus more on keeping banks happy. >> how are lawmakers responding to the idea of creating this agency? >> anytime you want to do something like this, it will create problems. many democrats support this.

it will be a matter of working out the details of legislative sausage making. but it enjoys widespread reports. for republicans, it is as it would be expected. ec had basically along party lines. >> what are republicans's specific concerns? >> they say that it would limit choice for people and would cost too much. the supervisors should be able to -- various arguments being put out there by the banking lobbyists and you see some of those same talking points. it is an interesting dichotomy. you see the banking regulators and that republicans all those in the creation of this agency. >> the chairman of the house financial-services committee, barney frank, openly challenged the industry over the debate.

does he think that he can have some sway with the financial industry on this? >> the financial industry will oppose this to the very end. they don't want any limits to offer would ever feel -- products they feel they can make a profit on. many are legitimate products. the idea of this agency would be preventing that. if your party prank or a democrat, it is an easy issue. are you in favor of the banks over seeing billions in government aid? >> what about introducing regulators at the or the fdic? don't they have existing consumer departments as well? >> all of the banking agencies had existing consumer departments. those powers should be taken away, most notably from the fed

, which is, under intense criticism for waiting for years to write some of these regulations, 14 years in some cases. and by that time, a lot of these bad loans that are causing us problems in the economy, all of those loans were written by the time that they actually reacted. for years regulators had these dual responsibilities and i slept on consumer protection. -- n/a slavkov -- and they slo ughed off on the consumer protection. >> this is part of a broader regulatory reform effort, and i don't see how they are going to meet that deadline. they say they are on track. i think they will be hard pressed with everything going on on health care. on the other hand, there is a certain window of opportunity for legislation this significant

to get through and to keep in people's minds the crisis that we saw last fall, and how important is to make changes. >> thank you. >> now what tribute to eunice kennedy shriver from 2007, held at the john f. kennedy presidential library. speakers included her brother, senator ted kennedy, and her daughter, maria shriver, why of california and gov. arnold schwarzenegger. this is a little over an hour.

>> i special welcome to our special guest of honor, eunice kennedy shriver. her brother, edward kennedy. joe kennedy and death. my role this evening is to provide some introductions of those who may be asking, who is he? i am paul kirk, and i am chairman of the kennedy library foundation. it is my privilege to co-host this evening with the ceo of our foundation and tom putnam, the director of the kennedy library. john and tom daly lead our staff

in such a great job here. it makes the board of directors so proud. there are members of the board here and we thank them for being here. and for their wisdom and support throughout the years. this library is an educational institution enjoys its reputation because of the distinguished visitor series that take place here. those could not be accomplished without the support of some generous sponsors who are among boston's upstanding corporate citizens. i wanted knowledge them. the bank of america and, represented by a member of our board. also the boston capital loan institute, the boston foundation, and the great beyond corp. -- rapeon corp..

and the new england cable news. i want you to join me in thanking them for doing such a great job in support of our work. tonight we have a special privilege to sit in on a conversation as if we were sitting around the shriver dinner table. what we will hear this evening, i hope, are eunice's children's perspectives on her contributions to public life, the lives of millions across the globe, and to their own lives as well. to help facilitate that conversation, we are delighted have professor mary ann mcglone and with us. she is out of harvard law school

where her scholarship on human- rights and bioethics received international recognition. she is a member of president bush's council on bioethics and receive the 2005 national humanities metal. she was appointed to the pontifical academy of social sciences by pope john paul ii and currently serves as its president. we thank you for being here and you will -- and we welcome you, mary ann, as well. [applause] later in the program, you will have an opportunity to participate in the conversation as well by questions or comments that you may wish to write on the cards, and staff will pick them up during the course of the program and submit them to mary ann, and she will selects some representative questions to be

addressed to our distinguished group on the stage. it is said that that purposeful life is a life of purpose. that lesson is best embodied in the inspirational examples of sargent and eunice shriver. those who were blasted be their children -- who were blessed to be their children, it is not surprising that they are doing what they are still doing with their young lives. body shriver, public servant, elected official, former mayor, city councilman, santa monica, calif., a tireless advocate for the homeless and other causes, created founder a product read with his partner, which donates

up portion of the profit out products with the color red to global issues. changing lives otherwise for hundred maria shriver, of ward winning television producer and journalists, books which educate and inspire and change lives those struggling with whites issues and looking for examples and i used to guide them, the first lady of california, and the catalyst for some many issues in that state. renowned and honored by all of us here. tim shriver, took its yield agreed to inner-city schools where he taught and change the lives of countless school kids for over 15 years before taking over the role of president of special olympics.

dimon linda -- tim and linda are at yale with their son for this important time for them. he is the founder of the choice program, changing the lives of at risk kids and counseling and job-training services. the managing director of the nonprofit save the children. directing nutrition and literacy programs for children living in rural and impoverished communities across the country. anthony shriver, founder and president of a nonprofit which began in his dorm room in georgetown and has changed the lives of more than 250,000 disabled individuals around the world. it transitions these individuals from institutions of isolation into productive lives into the

community at large. if you are ever asked for a definition for an inspirational agent of positive change, the answer is it is a shriver. this generation is just getting started. and let's hear it for the work that they are doing. some months ago we had a memorable event here in which we pay tribute to one of my favorite human beings, sargent shriver. sergeant's own career speaks volumes on the importance of unselfish service to a life of purpose. for most mortals, the vision, the genius, the tenacity, the

love that unit contributed to the global success of the special olympics would be nothing less than the achievement of an impossible dream. but it is only a part of the eunice kennedy shriver story. so as we did at sgargent's evening, it would be better to put this in a complete perspective by taking a brief walk down biography lane. this is how that story unfolds. she graduated manhattanville college, deployed in the special war problems division on the department of state, helping former prisoners of war to reorient to civilian life. social worker at penitentiary for women. social worker, house of the good shepherd, and the chicago youth

center for the chicago juvenile corporate executive vice president and later president, the joseph p. kennedy jr. foundation. the mission -- to identify the causes and develop a vengeance for intellectual disabilities. to educate society in erasing discrimination and providing hope to those so afflicted. inspired the establishment of president kennedy's committee on mental retardation, as well as the national institute for child health and human development. the driving force for the kennedy institute of medical ethics at georgetown, and a similar institute at harvard university. founder of community -- a program to help prevent teen pregnancy, drug, and alcohol abuse. presently serving over 1200 elementary, middle, and high

schools in 20 states and the district of columbia. founder of camp shriver, a day camp enabling intellectually disabled children to develop capabilities in sports and physical activities at the shriver home in maryland. can shriver was the precursor of the special olympics, which of course is recognized as a global force for a better humanity, providing esteemed and hope, achievement an opportunity to more than 2,250,000 children and adults competing in 26 sports and more than 150 countries are around the world. the purpose of life is a life of purpose. to open the program, i am certain that you will feel a powerful compassion with eunice shriver continues to bring to her life of purpose captured in

this brief film. [laughter] ♪ >> my mother has been a key leader in a field of intellectual disabilities. i think she has done more than sing it in -- any other single human being alive. and she is still striving to make sure that people with special needs are equal, are mainstream, are viewed as being capable and athletics, and she will not rest until that is a world wide acceptance. >> we had a sister, rosemary, who was challenged intellectually, and eunice would spend the extra time with rosemary, teaching her and making sure that she felt included. >> that was a good 40 years ago. i cannot think of a positive experience, really, for our

special friend than that. they had a special education, they had no special sport, and it was very hard in a classroom in the sixth grade to compete against someone who is doing math or geography. but if you can go with that same person out in a field and play a sport, our special friend will excel. >> it was really bad spirits -- that spirit that started the special olympics. >> today, many of you will win. but even more important, you would do credit to your parents and your country. let us begin the special olympics. >> eunice is tireless and peerless and reflects a sense of goodness. it is very different for people could say -- is very difficult for people to say no to eunice.

after president kennedy was sworn in, he used to joke that he feared seeing eunice because eunice always had an agenda. >> her fingerprints are on legislation, on schools, on institutions, on perceptions, and most importantly on individual lives. >> i see that i have rights and i have the right to live and enjoy life to our fullest. and still today almost 3 million people take part in special olympics and it started with one lady who gave 48 years of her life to show the world what we can do. >> i love to be with my special friends and i like to learn from them.

i learned persistence, and that's, i learned courage. this is the future. >> the love, the hope, to bring peace and to bring excellence to our special friends. [applause] >> was a happy event this is. it is such a pleasure to a ban as too moderate a discussion about a woman who has always been a heroine of mine.

she is also a heroine of benefit -- benedict xvi. the list of eunice's accomplishments that you just heard is impressive. but that those of us who remember what it was like when not very much was expected of women, it is more than impressive. it is mind-boggling to think of the passion, the intelligence, the energy, this year determination to make a difference that went into every single one of those accomplishments that paul kirk just listed. it is no back in the 1950's, eunice, if you had an x-ray deficient that let you pierce through the story is that society was telling about things to the real truth of the matter.

and when eunice saw what she saw, she was horrified, and to use her own words, she was enraged at the conditions under which mentally disabled adults and children were being forced to live. and when she saw there was no stopping her. people began to use world -- words like human world wouldn't, course of nature. even her brother a president, as we just saw, coward when he saw her coming. [laughter] she handed him recently to sign legislation and to establish national panels. it is said that franklin roosevelt had a similar dread of certain women. and it is said that when he went to bed at night, he had little prayer that he said. dear god, please make allen are tired. -- eleanor tired.

i don't know what the kennedys and strivers try to use that prayer on eunice, but if they did, it clearly did not work. as paul kirk has just reminded us, but cause for which eunice shriver is most famous is just one of the causes that she championed long before they were on anyone else's radar screen. in fact, in the 1970's, when bioethics' was aware that many people did not even know, she sought a danger approaching and she was instrumental in establishing the kennedy center for ethics at georgetown. in 1982, she founded the community caring program, for caring for pregnant adolescents. she had an incredible and stand for just the right way to tackle the particular problem -- instinct but just the right way to tackle the particular problem. her dentures kept growing,

spreading, and developing options. the community of caring, into the character education programs that are in many schools, and of course, most famously, the little camp in the backyard baker went to other camps, baker went to the special olympics and now the special lynn thinks that has gone international and has addressed conditions in countries where the intellectually disabled are still treated as they were here in the 1950's. those are just some of the reasons why, when social historians look back at the great transformations that took place in american society in the 20th-century, those are some of the reasons why they will class unity kennedy shriver -- they will place eunice kennedy shriver on a plane with other truly great american women who

enlarged the sense of the human family, of which we are all members and for which we all bear a common responsibility. eunice herself, i know what she is thinking right now. she is thinking, many other people were responsible for all of these accomplishments. she would name first of all her husband sargent shriver and her five children. we're very fortunate that four of those people are here with us tonight and are willing to share some of their memories of eunice with us and with each other. so starting in order of seniority, i don't know how you sort this out among yourselves, but starting in order of seniority, bobbie, i am sure that your mother is very proud that each one at you in his or her own way has carried on some aspect of her work. i wonder if you would say a little bit about her influence

on you, your chavis -- choice of location, -- of vocation -- anthony, d want to get in on that? >> you can do it in reverse order. the one up? >> no, go for it. [laughter] >> i would say that thing that i learned from both my parents, and particularly from my mother, and all of us have worked its starting things in an entrepreneur real spirit. rage is a good word. it was the first time i've heard that word but i certainly felt it in our lives. i felt her intense determination. one of the things that people talk to me about, they say that

my mom is so sweet and such a lovely person. which is true, but as i said to you earlier, i always felt a little bit like they say that maybe because she is a woman, maybe because that is what you're supposed to say about a woman. i felt her to be extremely determined end very aggressive. super on entrepreneurial. you seen that yourself. you cannot overstate love's determination. jack cowered, but so did everybody else. i heard about the stories when she tried to do the first games. people in certain places will not allow the games. she had to go out to chicago where mayor daley controlled a soldier's field and allowed it happened here you don't have

insurance or what they become upset, and so on. mothered just went out to mayor daley, got the deal for the olympics games. i tried at carry on that same spirit. when i feel daunted by what is happening, i think about what would mother do. run the motor. -- run them over. [laughter] that is what i try to do. [applause] >> marriott, if you have not always been happy with the way that the press speaks of your mother's i accomplishments, as though they were trying to put her in some kind of mold when she broke so many traditional mold. >> just a follow on what bob was talking about, one of the things that money taught me as a daughter -- mommy taught me as a

daughter was never think you cannot play on a level playing field with a man. you should not -- you should figure out ways to get around the no and figure out what is you wanted it. one of the many things i got from being raised by her was the understanding that you have to compete. nobody is interested in the struggle. they're just interested in the end result. do not cry. if you get tackled, get up. feel that you could go out there and compete on a level playing field because that is what she did. every time someone said no to her, she went around them and or rolled over them. that is a strong philosophy to get. it also approves the other thing about her -- she is relentless in what she wanted to get accomplished. that is a very important philosophy to give to anybody

who wants to start anything. no one has accomplished anything great without being relentless. you don't have to be the sister of a president. you don't have to be born wealthy or payments. if you have a vision and your let us, if you can probably get it accomplished to some degree. -- and you are relentless, you can probably get it accomplished to some degree. people always talk about mo mmy that she's part of the camp were started the special olympics. but she is a political operative and strategist. she worked both parties better than anyone i've ever seen. i don't think teddy -- teddy to speak to this far better, but i don't think we would have had any of the legislation that you have -- american with disabilities -- without mo mmy's relentless work.

you see her down to the hill today. she has been there 50 years and working both sides. i think that she was -- she always looked at it -- as what she wanted to get and how she needed to talk to to get what she wanted. she did not care what party they were in. she knew that she needed to get them and then she accomplished that. she did not get stuck in labels or party. she went into an accomplished what she wanted to do. herb reached -- special olympics are an extraordinary, but her political work is also. so much of the focus has been on that that the women in the family have also accomplice extraordinary things. sometimes people forget that mommy did what she did, that rose mary really was the catalyst for some much of the work that all of them have done. i am not taking anything from

teddy, jack, orebody. but there were some women in this family who are extraordinarily accomplished at time when people expected women who did not happen -- who did not have high expectations for women. it is even more extraordinary what they were able to accomplish when very little was expected from them. >> when you are right, it must of been in full force. >> that brought great points and it is important. my mother and father of a massacre day. -- go to mass every day. that informs her work. her perspective on power, i

would disagree with maria on nests, and anthony might jump in. but mother is on the ground working with people. paul kirk talked about her work as a social worker in chicago. she is actually out there and still in the back yard working with special olympics athletes. i think that really comes from a deep religious faith. it mother mesa's 8:30 a.m. mass in the morning, she is at 12:00. if she misses the 12:00, she is at 5:00. you can charge her progress by when she is going to mass. i wanna make that point. so much of what she does is about affecting social change, and she does work with powerful people. but you perceive power without a grounding in the fact that god is bigger than you and you need

to spend half an hour acknowledging that at, and she does that, that is an amazing example to all of us. my dad does it every day. if they go in there every day and they get down on their knees. they may be powerful, their brothers may be president, are other brother may be in congress, but they acknowledge every day that god is more important. they are trying to cut back change but to do it through a social justice mission. i don't want to get the impression that i have complex of them being jesus. [laughter] i went in there last week with my 2.5 year-old, and they talked through the entire service. mother said that was a great sermon.

he looks at me and says, she did not listen to a word i said. what she is really grounded in his god, acknowledging his presence and our live, and to pursue power or policy change without a knowledge in that god his important in your life is a hollow victory. that is what gives her so much energy at 86 to be running around not only this country but the world. the fact that she is down there with their special friends, in the swimming pool, and had a couple of maitre -- major medical issues but she is with her friends, and i think she sees in those friends god, and that we can work together to create a world that is based on that. i want to make that point. i don't know if you totally disagree with me. >> you just said everything i am about to say. [laughter] >> h as its priority for its privileges. >> especially in this family.

i always try to figure out what teddy and i share in common. we're in a family of, siblings. -- of dominant siblings. i think they have said so many good things. the only thing i might add is a slight modification of what mark said. mothers genuine commitment to the issue. as bob was saying, she has the power to roll the ball over. but most people would not tolerate that if most people did not think that she was sincere and that our values were in the right place. you go up to a senator on the hill and work them over hard. you could not do that if they did not think you were genuine, that he was senior seoul, and you were there for the right reasons. it is great -- that it was in

your soul, and you were there for the right reasons. no matter how big an organization can get, no matter how many staff people we have, why do i get back up every day? she taught me that when we were little, if you lost to hear -- people would tell you over and over is good enough for them. that resonated for me and my mind. it had four people in rem and say, well that is good for them. you would see them in a building, it would have 90 people with intellectual disabilities all living in the same building. that would say, it is good enough for them. i thinks she really believed all the time that it is never good enough for any of us. whatever work we're doing, it is never good enough. she wanted to keep going and going and never really stopped. that mentality, especially for

people with intellectual disabilities, to not accept is good enough, to not allow that to continue on is the thing that has really driven her and why she keeps going 100 miles an hour. to this day, as great as special olympics says, and her other projects are, it is not good enough. we have got to do a lot more and we have got to keep going. she has to start a new camp and her energy level has to keep going up. one group of guys went out on the audubon and the guy jumped and, so excited. i can drive as fast as i won. he is going 90 miles per hour, 120 m.p.h., this is incredible. he is in his car. and then he sees the exact same cart going by at 180 m.p.h.

for me, that his mother. she is in the same model that we are all in, but her model is at full speed. the cars maximum speed is 180. we are all about 120. she is not happy at 120. that is why she still goes of 180. that is why people in this building have been if that is so tremendously, because she is still running at full speed in her model. >> that takes care of one of the question. when you hear your mother described as a human world women are having superhuman energy, i wanted to know how that comports with the human -- the eunice shriver that you know? but i see that you did see that. a lot of people would be interested to know how the experience of during up in a

family where work-family pressures, keeping them and not proper balance, could have been a constant challenge. how that has helped you in your lives to work out that difficulty that many americans are struggling with? >> to staying in balance? >> anybody been able to do that? [laughter] >> i think we grow up in a family where there was not much balance. both mommy and daddy had meaning and purpose in their lives, but it was all about work. if my mother what in the room today, i do not sit on the couch. i jumped up and run out. [laughter] you've got to learn had just be. oh, no. that is certainly not the way that they lived their lives.

they lived their lives with a goal. i certainly think that mommy had a goal always, beginning to change the family -- the world one family at a time. she got involved with this watching her mother deal with her sister. and then others had no school to send their children to, no camp, and she was determined to change their world, and in she was determined that we would join her cause, and other people we knew would join her cause. and they got wrapped up in it. there is probably nobody here who knows any of us who is not involved in some capacity working for mommy. you walk in the door and you walk out what up in paper. you were involved in something because her philosophy has been that everybody has the ability to serve, so get on to yourself,

no matter what your age or where you are from. you should be able to do something. >> i was dead and all of the environment that we grew up in. but to be honest, able to not run around and started to face. i got picked set on accounts a little bit more. -- ipod to sit on the couch all of a bit more. i am trying to do it more now, all the bed. we grew up in an environment like that and for me and some of us, we're trying to chase that course a little bit. you learn an awful lot by sitting on the couch. to have a conversation for 20 minutes, not making them run up and down the field, and jump on the pole. >> my mother asked me, what is trying to be?

just being present. what is everybody doing. >> she does not like it. >> note, she does not like it. "what is saying?" >> you get this image of no one sitting on the couch. but the day began by going to daily mass and putting everything that was going happened during the day in a certain perspective, and relativizing power and all the other things. >> i definitely believe that. she has a unique way of looking at power. she seized power from broken people -- she sees power in broken people. in today's society, i don't think they frankly about you bet. we value money and the richest

people. mother definitely said, know how to work with those folks. but what may assert unique is that she is as easy and calm and comfortable with a disabled person, who may have a profound physical problem, as she is talking to plant eastwood or warren buffett. i think that is because she sees the value in humanity and the value and broken humanity, and sees that that is the sole goal, to pull that together and work together. i don't think she started out in chicago or in the backyard thinking, i am going to change the world here. i they see some families that did not have resources, started on a little by little faces. if you look great social movements, they always start with someone who is really doing it in their backyard or in their

house or is upset about something. they slowly gather steam and make a change. it often comes from the grassroots up and not necessarily the top down. but mother knows how to work the top down and the bottom up. that is where her unique power comes from and how she resonates with people. some political leaders who have more power, they are not remember 10 years later. they don't necessarily remember a policy that change 20 years ago but they remember when people thought that people's hearts. those of the people like mother teresa, up toward the day, the have profound impact. -- dorothy day, who have a profound impact. that ultimately is the great power. >> the other thing that is really important, when you talk about mommy, you cannot talk

about her without talking about the importance of her family. that is the joy of our life. her brother and sisters are really the sistersjoy of her life, and her parents spirit that permeates her whole life. everything is about her brothers and sisters and her parents, and the lessons of her parents and the loyalty of her brothers and sisters. always say to the five of us, i want you to be together and committed to each other. we are all in this together. this is family work. people that our friends, you are part of the family and part of the work. trying to extend that philosophy to our friends and their friends and so on. but the bedrock of money is really her parents and her mother's ancestors. -- the bedrock on mof mommy is

really her parents and her brothers and sisters. the importance of family, but importance of faith and family, and then the purpose of life, the mission in life, i think those are all connected. >> one last question -- now it is time -- wait, one more question. all of you agreed that the full extent to of eunice kennedy shriver's contributions to changing hearts, minds on so many issues has not fully begun to be recognized. when we think of those historians in the 20th-century it will be building the small pantheon of great american women, what would you want them to notice that has not been adequately noticed thus far? >> her.

when you look at the woman's hall of fame, you was see susan b. anthony and eleanor roosevelt, and you'll see eunice kennedy shriver. i would hope that people would look at her entire story. yes, but families came from, yes the family she created, but what was her goal, what was her mission? had she go about accomplishing that? she created something that did not exist before. she was relentless in it. she was a mother and wife. she was a sister, a daughter, she was a friend to millions, and she not only changed the back yard that she started in, the community they started and, if this date, the united states, but really the world. her mission may have started in the back yard, but the result of permission has changed throughout the world.

she deserves to be on the woman's hall of fame. . [captioning made possible by constellation energy group] >> it's the custom of the

kennedy library at these forums to take questions from the audience. and now i will open the envelope . the first one is, in a house full of children, do you have a favorite funny story that exemplifies your mother's personality? >> i would say there are so many of them you don't know where to start, but one viffied memory is when i -- vivid memory is when i would come home from school, we'd come home, she would park the car, and we would get out, and she'd say now we're going to have races. and she'd line up next to me, and she'd be like, i'm going to give you a little head start, and let's see who can win. she would race me every day after school, and she'd beat me every day after school. i think that's a pretty good image of what her personality was like. >> i will just take that and say

last year mother busted her hip, a couple years ago. her house in potomac, we live about a mile away, there's a circular loop in the house. she started in the middle, and my 7-year-old son and his buddy had to run the whole loop around the house and she ran the half a loop. >> she won, right? >> she did win. >> and the kids would loop her, and she'd do a little shortcut. my son almost clipped her a couple times and knocked her over. she did it multiple times. my wife came over. this was about 9:00 on a saturday morning. my mother terned to jeannie, and said, i beat your son. and she said in what, mrs. shriver? she said in a running racism -- race. >> mummy always hired people

with intellectual disabilities to work in our house. so a lot of times people wouldn't want to come over to our house, because they thought it was wild. there were 100 kids in the back yard with intellectual disabilities, there were 100 people working in the house that she was trying to train for jobs . >> the funniest part of it is the volunteers were from the local prison. >> in addition to the volunteers, she would -- >> people had a right to be afraid. >> she did hire convicts as volunteers. i would say, mummy, these people came from the prison. she'd say, don't tell anyone. >> we were there in that era. >> is it true that some of the counselors at camp shriver drank up all your father's favorite

wine? >> yes. when my father came back frbing ambassador to france he had gotten a case of wine from mr. rothchilds. there was punch on friday, and for some reason the punch guy hadn't delivered the punch, so someone did take the wine, empty it out, and make the punch. so when father came home, he was quite exercised. mother was like, forget about it. we didn't need the wine. >> mummy used the house as a training ground for all of her philosophies. so she wanted to see if people with intellectual disabilities could work so she hired people with intellectual abilities to work. she bleevened prisoners could be rehabilitated, -- believed prisoners could be rehabilitated so she brought them over to the house for counselors thinking they could be rehabilitated from

murder. she would try all different kinds of sports, archery. >> archery! >> we're not making this up. >> this next question from the audience, i don't know what kind of a pandora's box this is opening up, it says, "what did you discuss around the dinner table? >> how to avoid getting shot by an arrow, i guess. >> i remember when the news -- my mother would put pictures from the news all over the dining room, starving people. then not let us eat. she would put a piggy bank in the middle of the table, and she would say our dinner tonight would have been $30, so i'm putting it in this piggy bank and you will eat serial, -- and

you will eat cereal. she will call our children and say, i want to go to darfur, and my kids will say, don't make me talk to her, she's crazy! she has a peanut butter for malowi. she reads the paper and says why aren't you doing something about it? and she will send magazines and books every week to our house telling our kids why they are not in a project, what are they doing? and they are terrified of her today. >> i would say the article on the peanut butter is extra enriched peanut butter which actually is used for children that are starving to death. every scoopful is a huge amount of calories. >> 300 calories. >> yes.

the children where i work with in africa, she harrassed me for months to do it in other parts of the world. i run the u.s. side of it, i don't run the international side of it, but she got it done. actually we got a letter back through save the children, and it is now impacting the way foundations are funding nutrition programs in certain countries in africa. because mother put up the plone with a friend of hers and got rosy, our niece, to actually do it as a summer project. so it is not, you know, let's put peanut butter in africa. she read in in the "washington journal," -- "wall street journal," and was tenacious about getting it done. it's definitely, she sees the idea and understands the value of it, and then got it done. it's really impressive. >> i know as far as the audience is concerned that this discussion could go on for a long time, and it has been so

wonderful. but we have come to a point in the program where i must welcome senator edward kennedy and ewe niss -- eunice kennedy shriver to the podium. [applause] many

>> i think they did terribly well, didn't you? just a brief word, because we all want to hear from eunice. i think all the members of the family sort of captured eunice in such a special way. i always have felt as a member of the larger family that the great qualities which they picked up tonight so well was that eunice absorbed from my mother was faith. an extraordinary belief. and one that clearly impressed all of the children and certainly made the mark on all of us. the second was the family. you hear that. this is all really from my mother. and thirdly, that no one should really be left behind. she had that sense that nobody should be left out or left behind.

she picked this up and obviously in a very early age, all of us in the depeam could see that special relationship that eunice had with rosemary. for my father, it is the love of competition. eunice, you've heard those lessons of competition. the bailiff -- belief in the political system. not the politics that's glamorized or condemned today, but as an instrument for change. as an instrument for change. that when it is really done well and done right, in the way it was described today in building coalitions and the rest, it can make a difference in people's lives. that was something my father believed in very deeply. eunice picked that up and certainly learned from that. then we heard about the drive. you could use that extraordinary word "drive," or "perseverence." wonderful line from shakespeare,

"perseverence, lord make honor bright." that's been eunice. the final thing, i think she drnted the strength in our family that -- demonstrated the strength in our family that we could make a difference, and that you didn't have to be a united states senator to make a difference. and really the great power of eunice's life, although she has had extraordinary advantages, is the path way that hopefully will be inspiring to millions of people across this country. you hear the example about peanut butter. you could hear all these examples. starting something in the back yard. working with volunteers. any person, any family, any place, massachusetts, in any part of our country can pick up those seeds of examples. they are inherently a part of our value system in our great society. they were certainly part of our value system in our family and they are a part of value systems

that we see every day in families, so many of whom are here and have been such a support for eunice. let's give her a real kennedy library welcome. my sister, eunice kennedy shriver! [applause] >> thank you very much. thank you very much. i want to --

i want to thank you for the wonderful comments, the wonderful introduction. i think she's going to boston, and i think she's going to see the pope, and i can't wait to manuel herrera remarks about the pope. thank you very much. i also want to thank john shaddock who has been our president for over 40 years and i have been enormously grateful for all the remarks that have come here tonight. to paul kirk and everyone here in the library. i am grateful and proud to be with all of you tonight. most people believe that i have spent my whole life really interested in only one thing, and that one thing is working to make the world a better place for people with intellectual disabilities. that has been a huge part of our lives. it has inspired me to work research when i was young, to

create sports camp, olympics, and other programs, and to join with other children and their many causes and to add political leaders to make more comments about health welfare to all of the people. but important as it has been, it is not the whole story of my life. my life is about being lucky as a child. to be raised by parents who loved me and made me believe in possibilities. it is also about being lucky to have had these extraordinary children. i think we have met them all here tonight. and my friend in my work and my life. it is also being especially lucky to have a wonderful husband, to have extraordinary

children, five, and have them marry extraordinary wives and a husband. and to have extraordinary grandchildren, this also has been my wife. but in a strange way my wife -- life includes being lucky encountering the sting of rejection as a woman who was told that the real power was not for me. i am lucky that i saw my mother and my sister rosemary treated with unbearable rejection. i am lucky that i have had to confront political and social injustice around the world throughout our career. you might say why are we lucky to have such difficult experiences, and the answer is simple. the combination of the love of my family and this awful sting of rejection helped me develop the confidence i needed to believe that i could make a difference in a positive

direction. you would not be surprised that i know that those same qualities were also the experience that shaped apresident kennedy. truthfully, i believe rosemary's rejection had far more to go with the brilliance of his presidency than anyone can understand. yes, he was our country's greatest champion of what we all call mental retardation. to this day his legacy of the creation of the university affiliated centers the president's council remain today one of the great histories of our country. but beyond the work he did for people with intellectual disabilities, i believe it was rosemary's influence that allowed him and all of us to be vulnerable and read people.

i think i can say that not one among the thousands who have written about him understood what it was really like to be the brother of a person who has mental retardation. and tonight i would want to say as i have never said before more than any single individual rosemary had the greatest influence. so tonight with great gratitude to jack, and also to my wonderful sons and daughters, first i wish to each of you, the love of a family. and if that is impossible, the love of the family who would treat you like a family, because there is no love substitute for love. everything else doesn't matter. if you haven't got a family, go find one. secondly, i wish each of you the gift of being able to channel whatever injustice, anger, or frustration you spr to -- you have to a positive change.

you can do it. the only person you can convince is yourself. finally i want to offer you the chance to play or go to school or be friends with one of the 200 million people on earth who have an intellectual disability. i guarantee you that you will nerve go back. who knows, you may even become future president of the united states. so thank you for the evening. thank you for enforcing to me the power of faith, hope, and love. i have always believed these to be the most important gifts of all. i hope that many of you will join in my special mission to make the world safe for people with intellectual disabilities and make the world safe for human dignity. thank you very much. [applause]

[applause] >> and speaking of lucky, how lucky we all are to be in eunice's company tonight and how lucky the world is that she has done what she continues to do to make this world a better place. we all know that this institution is dedicated to the memory of former president of the united states. he inspired citizens of this

country and around the globe. but at least as an equal part of the story that's told here, if the other members of the president's family did and continue to do what they do and set examples in each of their lives, and eunice's story is as powerful as any of those, i -- when i think of eunice's story, i also think of what her brother said. the energy, the faith, the devotion we bring to this endeavor will light our country and all who serve it in the glow -- and the glow from that fire will truly light the world. eunice, he had to have been thinking of you. and we love you, we thank you

for your family, thank senator kennedy, we thank jean, we thank all of you for being here tonight, a special night about a special lady who has done so much. i only ask you as a final thank you to you, that you respect eunice's time and her family, as they leave the stage, and as they do, you are welcome to stand and give them all a rousing thank you. thank you very much. >> the house and senate are in recess for a district work poured and lawmakers have been hearing about constituents on health care legislation. we have been covering a number of these town halls and will

start showing them tonight at 8:00 eastern. senator ben cardin hosted an event last night at towson university outside baltimore. the senator also joined us on "washington journal" last week. here's a bit of that host: here is a question -- guest: well, i don't think anything went wrong. the medicare population is still the most expensive part. as you get older, you use the health care system more frequently. host: might take on this is that overall health-care costs for the nation -- inflation for health care for the country every year. guest: absolutely, because new

technologies, people want the latest tests, the newest medicines. as we invest more in medical technology and growth, you get new ways weekend do things. we now have the imaging, the types of procedures we can get back then. think about the number of tests that are now available that were not available just 10 or 20 years ago or three years ago. we have improved and helped technology. also, are democrats except change. we are an older society than we were 20 -- also, our demographics have changed. we are in older society than we were 20 years ago. guest: clearly, the emergency rooms. we should be using the emergency rooms for emergency care. we should not be using them as primary care facilities. those without insurance often have no option but to use

emergency rooms, extremely expensive. secondly, we need to have a wellness system. we have got to keep people well. if you do certain tests, you can detect diseases at a much earlier stage, much less expensive than the health care system. in some cases, you can avoid actually prevent diseases by early -- by using these tests. all this can clearly save us a significant amount of funds. let me mention technology. we talk about technology, but let me give you some of the facts. today if you go into an emergency room, it is unlikely that they will have the technology to get your medical history in time to avoid doing tests that may not be necessary. we want to technologies that we do not have to use the health care system as much as we do today, because we just don't know about your prior conditions, prior tests that you have, and

>> join us later tonight for ben cardin, health care town hall meeting. you can see us starting at 8:00 p.m. eastern here on c-span. >> now a forum on efforts to broaden access to health care. participants discussion the legislation currently before kng and outcomes of a massachusetts based health care program. this is just over 90 minutes. i want to welcome you to this program. i am with the alliance for health reform. thank you for breaking a hot weather in washington to come to

this program. you probably remember how cold you were the last time you were here and thought that was a great idea. to spend an aug. atherton in the air-conditioned comfort here. but that is not all of you were going to get for your money. you're gonna have one of the best programs you will have a chance to be a part of on the extent to which efforts to reform the health care system will affect the access to health care. i want to welcome you on behalf of senator rockefeller, senator collins, and our board of directors. you can be welcomed by them directly here in a moment. but while back, i turned 65 and became eligible for medicare. i got my card in the mail.

but i knew that getting that card actually meant i had to go out and find a new primary care doctor, because my previous one did not accept medicare. i eventually got a fine primary care physician and i appreciate your concern, but the point is -- [laughter] adding insurance is very important to getting access. after all, the institute of medicine indicates that 18,000 americans die every year who would not take -- if they have had health insurance but there are other factors that affect whether you actually get the care that you need. we're here today to talk about some of those factors. we know for example that there need to be enough primary-care doctors and other providers if people are going have adequate primary care access. and to the young professionals, they are not going into primary

care in our medical schools and associated schools. we know that relative to specialists, they have lower incomes. and they are reimbursed for up before a service. it offers no incentives for caring for patients in the most efficient, high-quality, effective way. a partner -- our partner in this as very strong interest in this topic. a self identified as working to help americans get the care that they need. we're very pleased that their involvement in the formulation and the execution of this forum. i want to thank david colby and their colleagues at the foundation for the interest and support. a couple of quick logistical

items. there will be a web cast available tomorrow on kaiser family foundation's website. you will find copies of materials in your kits. the biographical background on our speakers is far beyond what i have the time to take to give you today. you'll also find all that material on our web site. if you are watching on c-span, everything that the people have in front of them on paper is on our web site. you can follow along even with the presentations, the powerpoint presentations, yet that is what you want. at the appropriate time, and those of you in the room can fill out the green question cards in your packets and haul

the mob and we will ask the questions that we can get to. there are microphones at the front and back of the room that you can use to ask a question yourself. at the end of the briefing, i would appreciate you filling out the blue about creation -- evaluation forms. let me get back to the program. we have a terrific group of panelists today. respected analyst, people working on the ground to improve access, and it would give brief presentations. in return to a discussion including your question and we will start with susandentzer -- susan dentzer. she is not on an hour -- on air analyst for the news hour. she let our reporting unit focusing on health care and social security. if you rely on them as i do,

you'll have a sense of both the breadthe and depth of her expertise. we wanted to bring us up to a -- up to date is what is indeed the various bills on capitol hill. >> that you very much. belated happy birthday. it is great to be with you all this morning. timmy has fallen the dubious task of attempting to summarize the health care legislation in 10 brief minutes. some of you may know that the house what through this a couple of weeks ago and it took them more than three hours. you are going to get the speed read version of this. i wanted to begin to say, underscoring this point that access is about more than having just an insurance card. indeed, everything in these bills in some way, shape, and form is about access.

some time you see that this is an access or portability or a cost issue. you need to think about these things as being all interrelated. it would be great if we could just have the luxury of dealing with one problem at a time, but we don't, unfortunately. we know about the strengths of the u.s. healthcare based on the research of the last dozen years or so and about the weaknesses. we know that we're going to have to work and a lot of different arenas just to deliver on something that sounds as simple as access. that is what these bills are about. let me move through my slides here. i will quickly talk about the obama administration's reform framework, that top priorities, an emerging details. and now have nine minutes. here we go. there is not an obama plan, notwithstanding what you read, even in the "washington post," which praised the obama plan.

but there is an obama framework in which the bills coming out of congress are being organized. you see the attempt to address all of these issues, reducing the high administrative costs, reducing the rate of growth of health insurance premiums, aiming for universe legality of coverage -- moving toward universal coverage system, so that more people have access, providing portability of coverage -- you can have access to pay health insurance policy and then lose it in the next if your next employer does not offer it. the portability of coverage is an issue. providing a choice of health care systems is that feature. investing in public health measures in order to keep coverage affordable over the long run. we're clearly going have to have a healthier population. if you have health insurance that is too expensive, because most of the population is obese,

if you will not have access to health coverage. underscoring the point that all of these things are very much into related. the primary goals of reform, i think, could be summarized in to just three. insuring access to good health insurance -- coverage. we don't want badder mediocre health coverage -- for as much of the population as possible. we want to cover the uninsured but we also want to bend the health care cost curve. otherwise, no one will be able to afford access, it even the people currently insured. to recap, we know how people below age get health insurance. most people get through the employment-based system. some people do by at privately in the individual insurance market. some people get it through medicaid. and of course, some people are uninsured. how we broaden coverage and all the bills? we actually are proposing to

take all of the existing mechanism and stretch them. you can think of various safety nets. every single one of those would be stretched under the congressional proposals. we would shore up the employment based system and create a new pathway for other people to get insurance that is not strictly speaking through the employer base system. we would expand the safety net for low-income people, and some combination of all of the above is to be proposed in the bill. as i mentioned, but cost these it is extremely important here. -- the cost fees is extremely import here. that toppled line, they have been growing by two percentage points faster than per-capita real act of growth. per-capita real gdp. this is held pretty constant over time. there will be some differences this year because we had a weak

economy. but it has held to a surprising degree. why is that a problem? you could say that that is great because they help the economy is booming. yes, but. this is the -- are harvard college will be updating this soon. stay tuned for the new numbers. but what these economist it is look at what happens if health spending grew at just 1% faster than real gdp versus 2% faster than real gdp. " what happened to all of the other resources in the economy over this time? their calculation showed that if we were standing on the brakes and bring health spending down to just 1% faster than real gdp, we would cut 55% of the entire increase in the u.s. national income for now to the next 75

years to health care. that is if we slam on the brakes. that would mean we have 45% left over for everything else. defense, education, the national arts, and you name it. everything else you want to do if you're like that is not health care, 45% would be left for that. if we go to% faster, what happens? 124% of real national income goes to health care. everything we're now spending on health care goes into real gdp. all of the increase in real national increase goes into it. we sucks away resources that we are currently spending on other things. ask you how affordable health coverage will be in an economy where nobody is doing anything else but working in the health- care system, or buying health care? as herbert stein once said, things that cannot go on

forever will stop. we can be pretty confident that this will stop. but it will not stop on its own. we have to find a way to put on the brakes. how do we deal with all of this? let's take a piece about covering the uninsured. most of the bills for c i medicaid expansion, primarily aimed at picking up people who do not now have coverage who are in fact the board. it is a dirty secret that it does not cover about half the poor. we're going to stretch that safety net. you see the proposals cluster around this notion that expanding eligibility to 133% of the eligible poverty level. new pathways. we need to get more avenues to help insurance that more closely resemble what people get it they get employer-based insurance. if you are in an employer-based insurance plan, you are in a big pool.

six people -- six people do not have to pay more than help the people because all of the insurance risks are spread across a large pool. whinnied pooling -- we need pooling mechanisms. this is the secret behind the exchanges are gateways. we will hear about how massachusetts put that in place as well. they all in essence of the states that have exchanges worked eight ways or for the national government to create a national exchange. different avenues to create these pulls so that people have access. a portability credits would be granted people lower on the income scale to help them off for the coverage. a lot of debate is how far down you go for that. in addition, emerging from the senate finance committee, we have the notion of applying tax

credits directly to small businesses to help them afford coverage. this will help them sustain another aspect of the bill, mandated it on the house side, mandate on the employers to provide coverage, stretching that safety net. we had a number of insurance market reforms that need to be take place. the leading one is that if you buy coverage and the individual market, you could be subject to pre-existing condition restrictions. if you have diabetes, the insurance company can happily sell you an insurance policy that covers everything but your diabetes. someonthis is more about the ine market reforms. but big question is the role of the public plan. the public plan is also seen by those are in favor of it as

another way of ensuring access for people. a house bill, there is one national public plan. the senate health bill talked- about community health plans. and the senate finance committee seems to be coalescing around co-ops. but there is the need for another avenue, not just for access but also to enact delivery system reforms. and i will say more about that in a moment. i mentioned the employer and the individual mandates. another important focus of the bills to make sure that people are offered coverage and that they take it up. there seems to have been a growing consensus that the whole system is not going to work unless everyone is in the poll. the cost have to be spread across everybody. that is how we will keep coverage more affordable and overtime for everybody. we obviously have a lot of problems in our u.s. healthcare

delivery system, side by side with many streets. to a large degree, reform will be about delivery sister in -- system spirits and 75% of our spending is on chronic disease reform, a large part of the delivery system reforms will be figuring out of way to deliver on chronic disease treatment and care much more effectively. what do people have in mind for doing that? and house bill, brought a party handed to the secretary of health and human services to launch a lot of tests of delivery system innovations like accountable care organizations and we will hear more about that, medical homes, bayou based purchasing, etc. -- value based purchasing, except from -- etc. it works to expand people's health. you heard about midedpac on

steroids. i will spend much time on that because i am at a time did and then a couple of key issues on the work force. we're not going have access to care unless there are the right people in the right place at the right time to care for people. a lot of emphasis in the bills on more training primary-care doctors, expanding the pipeline of people going in the health professions, making better use of team care focus, with others delivering systems. and the major work in progress remains binding the revenues and the savings, putting that package together to pay for this. in on the senate finance committee side, this is still a work in progress. a lot of savings anticipated after medicare and medicaid help finance the cost. what is ahead? we take our hats off to the

famous yogi berra. prediction is very hard especially when it involves the future. i turn this over to the rest of our panelists. [applause] >> there's an excellent website called health reform.org, where you'll find a lot of appropriate material appeared and the kaiser family website updates on the major provisions on the bills. i commend that to you as well. now we're going to turn to dr. nancy dickey. she has eyes challenger of the texas a&m system. she is a family doctor by background. she does share a lack of

academic health centers association, and the part i am most proud of, she is a member of the alliance for health reform board directors. she is in a unique position to talk about how to meet america's need for primary-care practitioners. and how well the reform initiatives address that need. she says that every day. thank you so much for coming out. >> i'm delighted to be here. let me give you welcome from the board. as he said, i have a number of perspectives to look at the issue of primary care, including that i established and ran up family medicine training program and was the interim dean of the medical school for a time. the white conclusion i can draw is that this may be one of the biggest challenges ahead of us. was toppled bit specifically about primary care. there's current widespread debate and a good bit of data that says that we have an

adequate numbers of primary-care providers, however you want to slice and dice them. this is a list of groups we tend to look out as primary care providers. interestingly enough, you all look at young but if you are around in the 1990's, we have lots of people who wanted to do primary care. i talked to friends is said that they were a primary care and ichthyologist or dermatologist. -- anesthesiologist or dermatologist. people are scrambling to get out. but this group that is here in front of view -- unfortunately, some of the same things that has happened a primary care physicians, where larger numbers of our graduating medical students have chosen to go into some specialty care rather than family medicine, general internal medicine, or general pediatrics, as also began to take a toll on a cord that we thought would be a part of the solution, nurse practitioners

and decisions assistance -- physicians' assistants. they are drawn to specialities for many of the same reason. how hard they work and how long the hours are, and we will be talking about all these groups as we talk about the increasing of the number of primary care. the other issue i could not fail to address it that with the profound nursing shortage, and able -- and ordered to see a more -- north practitioners will need to be back of the members. -- we will need nurse practitioners that beat faculty members. -- to be faculty members. what this light says is simply creating more positions to train

more primary-care providers is not the solution. as you can see from looking at this, there are unfilled positions in every one of the primary care areas. 10% in family medicine, and some only 5%, but the reality that there are plenty of doctors get more graduates wanted to go into primary care. the problem is that they do not. and we will talk about the reasons why. the story is more challenging than what this life would indicate to you. while there are example 6% of family medicine slots that don't have money one training and then, there are substantial numbers of foreign medical graduates who come in to fill primary care slots. u.s. decisions -- physicians occupied a smaller number than the numbers you see before you. why did they not go into primary

care? how will they be able to attract people into primary care? the first is you, reference by susan, is money. i grew up in a small -- on a farm in a small time and they let this and to me, even on the small end of the scale. but you have to keep in mind that we do not let many down people in the medical school. they say, you want me to invest the same amount time to become a radiologist or family doctor, but over the course of my career, there are millions of dollars differential in terms of what i am going have to retire on or buy a retirement home someplace, and so and is part of it. i actually had a young person that came out to spend time with me while i was in practice, and thought she wanted to be a family doctor. elected me with great seriousness and said, if i did that, will i be able to buy a

house or car? yes, i think so. but the difference is that if i had the choice between $600,000 a year and $200,000 a year, for the same amount of education and actually less work hours down here than a copier, then an awful lot of people wisely say, why would i not want to go into dermatology instead of family medicine? there are other reasons. it is not about the money. when we get people into medical school, we do not mentor them or to tell them that family medicine were general internal medicine is a good place to go. many times today, we still hear students told that they are too smart to be just a family doctor. i was handing out scholarships and asking a young lady about who in her family was a doctor. she said her dad was. he was just a family doctor. i almost the check back.

that is the type of mentoring that we provide. they want to be respected and get that encouragement in the sub specialty care. they watch hospitals spend big dollars in order to recruit the neurosurgeon or the interventional radiologist. but the gut a primary care settings and often they don't have investment in the infrastructure to allow them to do information technology. it sends a nonverbal message. medical school recruitment. we have good data de young men and women who come from small towns are more likely to go into primary care and more likely to go under rural primary care, and yet the numbers of people going in a medical school increasingly represent metropolitan areas. that is where they get access to education a gift and the high end training. long hours, and additional

challenges for rural and inner- city areas that are difficult to me as well. you wonder why any of us would choose to go into family medicine. there are things that we can do. if we can enhance medical school increment. it is not in the bills, but we can talk about bonuses to schools that either have high at the variability or bring in students from rural areas or non-urban areas. we can do better mentoring. those numbers are not adequate. there are could general internist out there if we could talk them into telling their story more often. the things that are not in the bill, loan paybacks. many times when you were facing the end of this training, you want to be of the pi house and pay back your lungs. we were talking about that earlier. if they give you lung payback at $200,000 for primary care, it might look more appealing than

if you have to pay back $150,000 in loans, by house, and make a very small and, as your college. we will talk about opportunities for training. there will be opportunities for people who wanted trained in primary care. but there are plenty of vacancies despite the fact we close down a number of training programs because they could not fill their slots with students that want to go into primary care. the bill again creates lots of opportunities for additional training. the other thing the bill does is talk about the medical homes. we talked about this in the academy of family physicians and the academy of pediatrics. many of us thought that that's what we had been doing most of our lives, providing coordination of care, trying to help decide when they need a specialist. but the reality is that we have moved away from that in a lot of health care today.

patient self refer to pay it -- to specialists. they may have half a dozen doctors treating them simultaneously, all with prescriptions that do not fit well together perhaps. what these bills do is recognize the potential need to change the way we deliver primary care and called it the medical home. it is an approach to providing comprehensive care for children to adults. they have been very involved in trying to make sure that this definition is represented in the bill language. a couple of interesting quotes suggest that this is not a new thought. william osler from 100 years ago said that you treat the disease, the patient has, rather than -- let me just read it. i am doing a bad job. the good doctor treats that position -- the disease. the great doctor treats the patient who has the disease.

primary care embraces the whole thing. giving the financial incentives to create medical homes, to coordinate care, and hopefully in tights are some specialty colleagues to participate in the coordination rather than seem to be separate from that, could in fact move is in the right direction. we talked about what people do not going to primary care. there are certainly not an up there. you will hear from some people in massachusetts discovering that. let's talk about what thbill does to address some of these needs. loan repayment -- it increases the amount repaid if you go back in a primary care, up to $50,000 in some cases. that is about half what the average medical student goes out with in loans, more than they can currently get. they can also get a lower interest rate if they go into primary care. expanding the national service health -- the national health service corps. there is good that again. if we can entice these young

men and women in, the substantial number will stay in primary care even though they were considering of some specialty arena when it finished their payback. decided that what they're doing is fun. payment is addressed in several different sections in the bill. most of the time it is tied to moving medicaid paid to 100% of what medicare pays. since many of the doctor's face that medicare payment is not good, that shows you how low they are. we think that that is a step up. it addresses increasing medicaid payments, medicare payments, and the possibility of meat and update, separating primary care and some specialty breads. it talks about training and the fact that primary-care doctors tend not a practicing doctors. yet most of our graduate medical education is in

hospitals. maybe we should move trading house so what looks more like the practice you will do when you are actually out earning a living. but the money to support a graduate medical education specialty training is tied to hospitals. what this bill does is actually ties pavement -- payment to the opportunity to do ambulatory training. if you like it enjoyed, you were more likely to continue in that arena. we need to make sure that the dollar's fall the residence. -- that the dollars follow the residents. this bill would move doctors -- funded positions -- in the primary care arenas. as i said earlier on, that will not do any get unless you convince more of my graduates to go into primary care.

it's not that there are not enough slots but not enough people willing to go into those slots. we have to address those other issues before the transition of bonds' fill positions is going to do any good. it's interesting that there are a pilot projects for training into disciplinary. we tend to train in silos. even when we get out of practice, we all have to work as a team. the concept that this team will be more he dissent than any one of us deficient -- individually is an interesting concept but one that we do not have any money to train toward today. . extension of the geographic for for, they will pay more for a rural area. that's a huge step forward, by the way. up until now, they were tied --

when you were in a rural area, it costs you less to practice there, and they actually paid you less to go to a rural area rather than to go to the same or more. despite the fact that those are some of the most challenging work areas. i had in here because i believe sas as we do the research for the time, we will discover over and over again that starting at primary care is the best bang for your buck. so i can't think of anything that's going to advance primary care more than us having -- actually investing in our being able to deliver care with the smallest number of dollars as opposed to proving that the new pill is better than the sugar pill which is better than the existing pill, which is what we do most of our research on today. .

we're going to turn now to sort of a case study of how this works out in a specific place, that is to say, the commonwealth of massachusetts. commonwealth of massachusetts. we've asked next two speakers to address, first, private sector approach, and then a public sector approach for dealing with the question of access. that means we're going to hear next from debra devoe, the executive director of community

transformation of blue cross/blue shield of massachusetts. one aspect of her work is the dramatic new initiative on payment reform which was recently launched by blue cross/blue shield. the c.e.o. of that corporation, i was delleding -- telling debra before we started, he's been describing this initiative at meetings of a commission he served on and that i attended meetings of and it is a fascinating experiment. while the congressional negotiators struggle with how to reshape health system payment for care in a way that encourages high quality and cost effectiveness, deb and her colleagues in massachusetts are actually starting to do it. we thought he'd ask her to try to explain a little bit of how it came to be and how it's working out. thanks for coming, deb.

>> my role will be to talk about how payment can help support access. i'll be eager to hear your questions on how this will work the vision of massachusetts, similar to the vision of our country, i think, is to create a system where all have access and it's safe and affordable. the challenge for the plan is when physicians, hospitals, and patients look at how we pay for services, what they could say is we do not pay for any of those things right now. we're not paying physicians and hospitals differently if the care is safer or more effective. we're not recognizing them if they manage to produce more affordable care. so we, as health plans, and blue cross of massachusetts feels strongly that we need to

play a role in changing that and let's start to pay for the things we all want, safe, effective, affordable care. as you'll hear from sharon in a moment, our state took the first steps to try to provide coverage to all citizens in our state. but we immediately, once we made access to coverage available, we immediately bumped into the issue that care was still not affordable, was not the safest care that we think we can provide as a system, and was not necessarily the most effective. we have grave concerns about losing the broad coverage if we can't a -- if we can't create affordable care. what we have begun to do is to offer an alternative contract to the providers that are in our network in the state of

massachusetts to not -- it's not required for participating in blue cross. but what we are able to say to providers is, if you're prepared to accept accountability for cost of care, effectiveness of care, safety of care, you will be recognized. with greater revenue. if you can produce that. so the basic structure of the relationship is that we've created long-term partnerships. of course in health care, long-term is five years. but the idea being that one of the barriers to physicians and hospitals being able to restructure the way they do things, that they live year to year, not knowing what their payment will look like. most payers make decisions about how they're doing to structure payment on a year-to-year basis. what we've done is say to providers who are willing to commit to a long-term,

five-year contract, we'll guarantee their payment levels over that five years. which gives them the opportunity to think a lot more creatively about how they want to recognize the efforts within their system to change care. and the contract does, for both outpatient care and inpatient care, pay differently, according to the results of that care. rather than just paying for each service that's provided. so this chart shows you the basic structure of the contract. the blue bar below the line establishes a budget per patient a global payment, that the provider is paid regardless of how many services they provide. they're no longer insented to do -- incented to do the m.r.i. or provide a service unless

it's going to create the most effective outcome for the patient. and the provider is freed up to offer some services that might not be recognized or paid for in a traditional fee for service model. what we feel the global payment does is to get the insurer out of the way of doing mother may i utilization review. is that admission needed? that decision is left in the hands of the providers, and if the admission to the hospital isn't needed and the providers can avoid the admission by offering services in a different way, they're recognized for that. the second component of the five-year contract is, there is a guaranteed inflationary increase each year of the contract. but this is where the benefits to those who are purchasing the care, the employers or the individual member, is realized because that increase, that

year-to-year increase, is lower than the increase that we're experiencing in the rest of the system. so if the rest of the system is producing a 9% to 11% increase, the increase annually in these contracts is much closer to c.p.i. much closer to the level of inflation that we're experiencing for other services in our economy. and then the final component, which is the component we're most excited about, is recognizing quality. and so, for us, putting significant dollars behind recognizing those providers who offer better quality of services is really the most important part of this contract. we'll -- i'll show you the performance measures specifically in one minute, but one of the key questions we often get for those that lived

through the capitation models of the 1990's is, haven't we done this before? and why is the alternative contract different? we certainly have experimented with capitation previously in this country and with some disastrous results for certain physicians and hospitals. we feel there are a number of differences that relate to how the budget is constructed and the fact that we are now able to better predict the expected health care costs of members than we were 15 or 20 years ago. however, we do feel that we need to continue to look very carefully at how these budgets are constructed because there's still things to be learned and we obviously, we're protecting the providers from unexpected insurance risks. so the cost of a neonatal -- a

baby who needs neonatal care or someone in a car accident, those things that aren't subject to better management, insurance problems. so we feel that the global payment of -- that can be done in 2009 is a different one and subject to better predictive science. so the -- i'm not sure if you can see these well on the screen, but we've established performance measures that are nationally accepted, well recognized measures of care. these are not measures that were uniquely developed by blue cross, partially because we feel that providers have developed measures that they believe are important and that can be measured in a valid way. partially because we want these measures to be able to be adopted by other payers, we recognize that any single plan, blue cross of massachusetts covers about 30% to 35% of the

people in our commonwealth and we know that even if all our members were in this arrangement, that it's very hard for a physician to completely restructure their practice for 3030%, 35%, even 50% of the patients. we want to collaborate with other plans, whether it's medicaid, medicare, the other commercial insurance plans in our geography to adopt similar measures so that the physicians and hospitals can perform across a common set of measures for all the plans. we think that's going to be the best way to move the dial. not to have different measures for different plans and, you know, cause the physicians and hospitals to be trying to move their performance across a broad variety of measures, but to limit that pool. so these are measures both for the hospital and for outpatient

care that fundamentally address the structure, the process, and the outcomes of care. the other thing we thought was exciting about these measures is that we initially provided the same weight, financially, in our incentive plan for all the measures, because we felt there wasn't any science around how to weight those measures differently. when we took the construct out to the providers, the physicians said to us, don't you care a lot more about the outcomes than you do about the structure and the process? don't you care a lot more about whether a patient's gotten a hospital-acquired infection that was avoidable or a complication after surgery that's avoidable or that their blood sugars are at the right level than you do about some of the clinical process measures. we said, sure, but we know

those are harder to achieve. the physicians said, why don't you triple weight those. weight those measures so if they're achieved, you get paid three times more than those measures that are structure and process. and that made a lot of sense to us because, like many other people, i've bought an exercise bike. that's the structure. i may have used my exercise bike. but unless i actually lose weight, lower my blood pressure and i'm in better physical health, buying the bike isn't really enough. that's what physicians were saying to us. even if we put in the right structure and the right process if the outcome for the patient isn't achieved, then there's a problem. so we have triple weighted the outcome measures. and then finally, we've created a scale so that those physicians who achieve the

highest rates of performance that are possible, so in other words, we're not setting the highest gates at a level that is not achieveable, will be paid significantly more. and our belief is that with this type of payment system, the incentives for the delivery system to restrubblingture, because the only reason for payment reform is to allow providers to restructure care will enable some of these fundamental problems and access, including fundamental care, to be reimbursed appropriately and -- in terms of care and efficiency and can help solve the problems of access. >> thank you very much, deborah. [applause]

>> as i said, we're going to turn now to a look at what government in massachusetts and the people who are subjected to it have done about access questions, and we're going to hear from sharon long. sharon is a senior fellow the urban institute health policy center here in town. he's a health economist of national reputation. she directs the urban institute's evaluation of the massachusetts reform initiative as well as the massachusetts household insurance survey for the state government itself. she's also doing evaluation work on a number of other state reform efforts, so she has a perspective that's uniquely useful to trying to take a look at the reform measures in massachusetts. there's a health affairs article, the gold standard that sharon has written on massachusetts, and it's in your packets. there's an electronic version

available through our website at health affairs that updates that paper. i commend it to you. sharon, i'm very pleased to have you with us, tell us a little about what's going on in massachusetts on the public side. >> thank you. my job is to give you an update on a real world health reform example. let me start by acknowledging the funders for this work, blue cross blue shield of massachusetts foundation, and robert wood johnson foundation. i changed my slides a little bit, i took one of susan's slides, i want to give an update to what she mentioned. as you remember, it was to improve access to care, cover the uninsured and bend the health care cost curve. as we look at massachusetts, i'll go into more detail on, but massachusetts has significantly improved access

to care. this was before implementing all the elements of health reform. before the minimum credible coverage standards were implemented and before the small businesses could buy into the program. significant gains there. in addition, this was before what some are calling round two of health reform in massachusetts which is, the state made the decision to address expansion in coverage and access to care first and then turn to costs, and that's where the state is just beginning to now address the costs. substantial progress for the first two goals, just starting oven the third. the work i'm reporting on today is based on a survey in massachusetts, we did a baseline survey in fall of 2006, our prereform world, then we did follow-up surveys in fall of 2007 and fall of 2008 and we're working on funding for fall of 2009.

we're looking at how insurance coverage, access, use, and affordability has changed as it's been implemented in the state. one limitation is that we're looking at changes over time so we capture health reform and other changes other time. in this world we capture the effects of the recession and the impact of rising health care cost as well. it's not a pure measure of the impact of health reform. what i would caution is those two effect the recession and rising health care cost would dampen the health care reform. we're probably underestimates what the health care reform would have got if the economy had stayed stable and medical costs had stayed stable. let's look at the findings. the impact of reform on health insurance. this shows insurance coverage in fall of 2006, which is the yellow, fall of 2007, which is the blue, and fall of 2008, which is the purple.

the first set of bars are the overall population, the second set is lower income adults, and the third set is higher income adults. lower income is 30% of poverty, the cutoff for our comcare program. there were significant increases across the overall population and the low income group and high income group. for the low-income group, it was at 96%, nearly universal coverage in 2006. this compares to 80% in other state, well above what other states were seeing. most of the gains in insurance coverage were among low income adults. there you can see a gain from 76% coverage in fall of 2006, to 92% coverage in fall of 2008.

a substantial gain over the three years of health insurance reform. i should note here, i'm not showing it in the slide but the increase in coverage in the state is both gains in public coverage and gains in employer-sponsored insurance coverage so we don't see crowdout of employer-sponsored insurance coverage. we attribute this to the individual mandate, we're seeing a takeup of coverage in the state. in addition to seeing gains in insurance at a point of time we see gains in continuity of coverage. looking at this slide, which shows people who had coverage for the full 12 months, you can see substantial gain there is as well, so less cycling on and off of insurance coverage which should translate to more coverage over time. when we turn to look at access and youth, -- and use, we can say the gains of coverage have translated to gains in access and use. the first set of bars is having

a usual source of care, people who have somebody they see when they're sick or need advice about their health. as you can see, we see an increase in that under health reform. the next two sets of bars are looking at doctor visits, any doctor visit and multiple doctor visits. again you see a gain in access. more people are seeing doctors and more people are having multiple doctor visits over time. to place these in context, 83% of dulls in the u.s. have a usual source of care, compared to 92% in massachusetts, in terms of doctor visits, 78% of adults in the u.s. have a doctor visit and it's 85% in massachusetts. so we see better access to care in massachusetts and gains in access to care under health reform in the state. wuven limitation of the survey we've done is we can't identify people who gained insurance coverage because of health reform. all we have are three

cross-sectional pictures. what we wanted to know was whether the gains in access just from obtaining insurance coverage or was it from other people in the state because there were changes in the minimal credible standards. we looked at people who had employer-sponsored coverage for the full year and with that population we see gains in access to care for that group as well. it looks like massachusetts reform effort expanded coverage and improved what counts as coverage in the state, so there are quains on both fronts. consistent with that, we see gains by income level, most gains in access are among the low-income population, that's the group that gained the most in insurance coverage. we also see gains in access among higher income adults. one of the things we see, people are more likely to get preventive care. that's one of the big changes when preventive care is covered before the deduckable applies.

the gains are more broad based than those who gained coverage. another way of looking at access to care is to look at unmet need for care this slide is reporting on people reporting unmet need for care for any reason. we looked at a need for doctor care, specialist care, medical test treatment and followup care, prescription drugs and dental care. i should note here, though these look high in levels of unmet need if we look at a survey with data from other states, massachusetts tends to be lower than other states. massachusetts has lower levels of unmet needs but still has unmet needs in its population. what you see is strong reductions in unmet need in fall of 2007. and then some offsets of that in fall of 2008. a bit of a paradox. we saw increases in access to care, more people going to the doctor, more people with more doctor visits but more reported

unmet need for care. it's clear that there was a push up in demand for care in the state and people had a harder time getting care. if you look at the sources of unmet need on the far right corner, it's specialist care and medical tests and followup care where we're seeing the unmet need as people are trying to get care. what it shows is that people -- as people are trying to get care under health reform in massachusetts, they were running up against the capacity of the provider supply and this was an issue prior to reform that's become more of an issue as more people have care in the state. we added -- because we've seen some indication of this last year, we added a question to the survey this year to gather information about difficulties in obtaining care. i can look at this in 2008 but can't tell you how it changed over time. in the far right hand bar, one in five adults in massachusetts in 2008 reported difficulty in getting care either because the provider was not accepted new

patients or was not accepting patients with their type of insurance coverage. more difficulty -- some difficulty finding providers. this was reported for both primary care and specialty care, it's not purely a specialty care phenomenon. it's more common along lower income dulls and adults with public coverage than among higher income adults and adults with higher coverage that may reflect the expansion of the coverage in massachusetts, a large part of it is in the public programs, and that was within four plan, it was a narrow provider network that had an increase. we are seeing some difficulties getting access to care in the state. the next issue we looked at was affordability of care. health care cos in massachusetts are going up as they were in the rest of the country. that predates reform, it's not a function of reform.

we're seeing some effects of that on reform. here, as in the access measures we saw gains in portability in the first year by fall of 2007 and then by fall of 2008, some loss of ground on those measures. so that we no longer see the significant gains or significant improvements in affordability over time. based on these findings, it does look like the trends in rising health care costs in the state are starting to undermine some early gains in affordability under health reform. i just wanted to -- part of what massachusetts was able to achieve was bringing together disparty stake holders to come together and agree on a the re-form initiative. everybody gave a little bit, everybody got a little bit. that support was strong in 2006 when we re-form passed and that support has remained strong despite much press about the cost of reform and unexpected higher levels of enrollment

relative to the numbers before. when we look at higher and lower income, it remains strong, gender, supportive, different ages are supportive. it's amazingly uniform across the state that supports -- support persists for the health reform initiative. let me recap what we know. there were significant gains of insurance conching in the united states. there's no evidence that private insurance is being crowded oout. there were significant gains in access to care as people gained coverage and kept coverage for the full year. there was some significant improvements in affordability. despite the sesses, there were some indications of problems over the last year. there's some loss of the early gains in affordability as health care costs have continued to rise in the state and limits on provider supply with the increased demand for

care created barriers to care for some people in the state. finally, as i mentioned earlier, health care cost is really round two of health care reform in the state. massachusetts is just beginning to really address health care costs. it's clear that the sustainability of health reform in the state will be a function of their ability to bend that cost curve, just as it will be at the national level. thank you. >> thank you very much. thank you, sharon. we've come to the part of the program where you get a chance to ask questions. as i say, there are microphones you can go to to ask them, you fill out a written question on that green card and hold it up, someone will bring it forward. let me just start, if i can, sharon, with one of the pointses you were making about

what the rere-forms are starting to do to access even as people are having more frequent doctor appointments. there is a -- in the materials, there's a survey taken in a number of cities that seemed to say that folks in boston were having more of a difficulty over time than those in most other places in the country in getting an appointment to see a physician. tell us what you think of that. and whether it's something we have to watch out as we work on access more generally. >> i think there's actually other evidence from the massachusetts medical association that is consistent with that, that there has been kind of more demand for care and more -- with that more waits for care. if you look at kind of the timing of the increase in coverage in the state, it's clear, enrollment happened faster than the state expected. it's a good thing, people got coverage, but it happened within a relatively narrow set

of networks. there was a strong increase in demand. what we think will happen over time we don't have the data, will be that some of the pent up demand will beesed as people get care and get followup care and the demand should be mitigated. what we're seeing is people have coverage for the full year, it's in the cycling in and out. as that happen we expect some pushback against that demand. >> susan? >> i think this underscores why delivery system reform is such an important component of overall reform. we all know the phrase, you get what you paid for. what happens now doctors get paid, when you come in to see them. if you look at systems that have moved away from fee for service, like kaiser perm nene the, a cap tated system we

published a study that looked at what happened when kaiser put in place secure email capability between patients and their physicians and lots of other interventions so you didn't necessarily have to come in to see your physician. what happened? visits dropped by 25%. people, it turns out, don't really want to get in the car and drive three hours to see their doctor, if they don't have to, nancy. i think you'd concur. the delivery system has been frozen around the way we pay it. as we think of new ways to pay the system, the system will break up these frozen blocks of turgidity and do things like use email and do other kinds of things that will make it possible to have more encounters, if you will, with individual patients and free up capacity to be used in those directions as opposed to just in the old-fashioned visit. >> we have someone at the

microphone. identify yourself and let me ask all of you who come to the microphone to be as brief as you can to allow us to get to as many questions as we possibly can. >> al, a.m. media, how do each of you see abortion access and coverage affecting overall health reform? >> you can see everyone's leaping to answer that question. and if we have no takers i'm going to have whiff on it. nancy do you want to take a crack at that? >> i guess i don't think it's going to have -- i think that it's another set of services that some doctors or providers will perform and some will not, some payers will pay for and some will not, i suspect that it's just not an issue that's going to substantially tip this

one way or the other, though it does have the potential, i guess, to elicit enough polarization that it could perhaps be used to either push in favor or push against reform. but i would think we should look at it as a service as opposed to something that ought to define whether this wins or loses. >> david, georgetown medical school. massachusetts, to begin with, isen in a far more favorable state in terms of medical resources, both primary care physicians and specialists and substantial community health centers. were there to be an analogous reform through congress, address the work force issue because it appears on the two

years that that's already a serious problem and a very favorable, probably among the most favorable situation we have in the nation. >> one comment, i agree with you that there's some aspects of massachusetts that are very favorable. we had a lower uninsured rate than other parts of the country and as you point out there's strong, academically, sources for medical education in massachusetts. however, there's also some big challenges, for example the cost of living in massachusetts and the ability to maintain a lifestyle in massachusetts, and as nancy was saying, as a practicing physician there, earn enough to live there. so we feel that while there may be aspects of the experience in massachusetts that are easier to achieve in our state, there

are probably some issues in other states that are going in the other direction. but i think what is going to be similar is that creating access to coverage will immediately bump into the significant problem of affordability and that fundamentally, though that affordability issue may vary a bit between states, i do think we all have that issue that the cost of care -- costs of care are grow manager rapidly than what we can afford to cover. i think the work around how to restructure the care so that it's more affordable may be more similar across the states. does that answer your question? >> if you're going to speak, you should speak into the microphone, if you would, please. >> i sense from the preliminary data, the issue of actual

access, more physicians not taking people, particularly lower income people, therefore a greater discrimination in who you see and apparently from back d -- backlog of people able to get access to care they wish. >> i think what massachusetts is trying to do is address those issues to provide incentives to see the patients in primary care settings and make adjust. s susan was talking about. health care costs are high for the massachusetts than the rest of the country and are rising fastener massachusetts. so that piece is not the positive picture in massachusetts that other aspects are. >> just to underscore what nancy aid earlier, the main focus is primary care. it's clear from barbara's and others' work, primary care is correlated with the most cost

effective, highest quality care. if you've got access to a primary care physician or primary care providers, you're going to have better care overall. that we know. we have this crazy system, as nancy said, go back to, you get what you pay for. we take the people in the system who provide the best, most reliable, high quality care and pay them the least. what's wrong with this picture? how did the system get this way? then we take the people for whom, frankly, specialists, many of them are wonderful people if you know much about the evidence base in medicine, the evidence base for a lot of specialty medicine is pretty thin. we take the people who are applying the things we have the least amount of evidence about and pay them the most. what's wrong with that picture? we have to undergo the process so that we're paying more for the stuff we have a sense

provides better quality care and less for everything else. if we all think this is going to be easy, mention this to our average highly paid medical specialist. but over time we think we can make some progress. social security why the gradual reforms will be important. >> i do think it's worth adding, though if you go back to the 1990's when managed care and capitation briefly held sway, it may not be -- it will be every bit as painful as susan and the others have said, but it may not take as long as we think it will. during the 1990's a decade of reform in terms of how we paid for care we created tremendous numbers of new primary care training programs, filled them, probably the only time in my history, with the top students in the classes, it was the place to be because we thought we were going to change the way

we paid for care and what we valued in this country. so if in fact reform can begin to show that there's a, going to be -- going to exist for a while, not just a couple of year, and that we're going to shift what we pay for, i think we'll in fact find many graduates who begin to look at primary care much faster, perhaps, than we had originally anticipated. the 1990's is the evidence i have to look at. gary krystoferson, former d.o.s., congress. we built an inner city, public-private community health system in one of the largest cities of the united states. we learned what you need to produce healthy people and healthy communities. the approach to health reform

to date has been slices. good slices like primary care, health insurance, this kind of thing. speak to me a little bit about what we really need, what's missing from the health reform discussion about if you really want to build healthy communities and make that happen. >> i think most of health policy experts and public health experts in particular agree there isn't a whole lot of emphasis on public health in the reform bills. there's system. there's -- there's some. there's more focus on preventive care, etc., etc. but we look at some of the situations we face now, for example, the obesity crisis, we know we need to bring more to bear on those problems than just insurance coverage. i think that the whole issue of the so-called social and economic determinants of health that is to say your health status is to a large degree going to be determined not at

all by your health care access and the treatment you get in the health care delivery system, it's going to be determined more by fundamental factors like your income level, did you grow up next to a toxic waste dump or not, all those kinds of things. that will be a work in progress. i think everybody agrees, the public health system in particular, is going to have to address much more assiduously in the years ahead. >> but again, to take a more positive perspective, i said earlier i'm a pessimist, but i don't want to be. there are pieces, in at least the house bill that increase building infrastructure for public health. there are specific sections that address the value by attaching payment for things like smoking cessation, things that have not been included in an awful lot of payment mechanisms. so i think that perhaps if you add that to the concepts of

patient centered medical homes and accountable systems, we will in fact have opportunities for a number of these communities to begin to grow up, if you will, and then because we're very competitive we may find that we can use those communities to eourage others. that the cost of care goes down if you have the infrastructure of public health and the primary care overlay and we begin to use those to put the next layer. i don't think we'll get this all done in the first cut. but we've proven, as you said, that the we take it a slice at a time, we don't make any progress at all. >> i'd just make the observation that most frequently i've read criticism that these bills do too much or try to do too much, rather than that they don't try to do enough. there are at least a substantial minority in congress saying, maybe we're biting off more than we can chew. we have a whole raft of questions about -- why am i

blanking on the nonsexist word for manpower -- >> work force. >> work force issues. let me attack a few of them, they are related. one of them has a pretty simple solution for the shortage, why not make medicare and medicaid acceptance required of all providers in order to close the access gap? sounds like a reasonable idea, doesn't it? >> didn't massachusetts try that? >> would your massachusetts people like to address that? >> i'm not sure exactly where the question is coming from, physicians are required -- >> one of the ideas floating around as these bills started to get marked up was the idea of linking participation in

medicare to participation in a public option, a public plan as a way of making sure that access for that group of people , presumably more the subsidized folks, would be relatively guaranteed since doctors and hospitals couldn't afford to write off medicare. as i recall, it was not met with unanimous approval. >> i'd say that's the understatement of the day. >> that's perhaps the answer to the question. >> a fundamental issue here is, are you going to require providers to do certain things, number one. but also, what are you going to pay them. now in medicare, obviously, the federal government has leverage to control what physicians are going to be paid. that's what we've been talking about, some of the payment reforms that would basically make it more attractive for pry prie mare care physicians in particular to see medicare patients.

on the medicaid side it's more complicated because medicaid is jointly run between the states and the federal government and jointly paid for between the states and -- between the federal government and localities. to raise rates in medicaid means the states have to go along with that as well, and the states are in a pretty injured state with their economic considerations and fiscal considerations. how we address that over time will be an issue. in the house bill, the medicaid expansion that would take place would be entirely paid for@@@@ if is not obvious that patients -- payment rates get what up and medicaid. you can see how low that they are, but there are serious barriers. until they are addressed, and access for medicaid patients will be an issue.

>> they are often times as much as 30% of new what medicare pays, which is perceived in misplaces to be probably 80% of what private insurance pays. now you are getting down to a fraction of the cost it takes to drive the process. implied, is that while physicians and other health care providers are not a big enough group to kill health reform on their own, if they in fact are incensed enough to try to get all their patients opposed to a bill, they can in fact at least seriously disrupt the likelihood of passage and mandatory participation would probably be adequate to get that kind of activity going. >> and this one actually

addresses the same question at a state level and initially it's directed at you, sharon. how have state government payments changed since 2006 to doctors and hospitals and how has it affected or how will it affect access in your opinion? >> one of the things massachusetts did was to raise medicaid payment rates for physicians and hospitals. they did address that. they're not as high as i'm sure the doctors and hospitals would like to see them, but they were moving those up to address the capacity issue. and i think, you knowing one state that's done this, along the lines of the earlier question, is minnesota, which says if you want to participate in medicaid, you have to participate in the state government health insurance program. ways to tie them together to come into medicaid. >> this one addressed to both of you who are familiar with massachusetts' situation, were co-payments, or are co-payments

and deductibles included in these insurance programs and have they been at snerd >> they are still included. >> that's not affected by the changes in your payment ex-personality, then? >> in the blue cross blue shield contract, we are applying that contract to our h.m.o. right now and employers and members can purchase different types of benefit packages but all of them include some level of co-payment or dedubblettable in the product and what we want to do, as an earlier question addressed, is to start to introde some alignment between the members and physicians so that lifestyle issues, members who are focused on maintaining their health, either throw smoking cessation, weight loss programs, etc., on the other side do get rewarded for that, in addition to having co-pames and dedubblettables for medical services. >> one thing the state did with

minimum credible coverage, setting the floor of what counts as insurance in the state, was setting limits for the out of possibility costs could be for the year. there are some pushbacks on out of pocket costs and for people eligible under 150% of poverty, there aren't co-pays. there are some limits on -- aren't subject to co-pays. but there are some caps on how high they can be. preventive care is now for everybody in the state, for the insurance to qualify it has to be outside the dedubblettable, so you've seen an increase of preventive care in the state. >> continuing on the same theme, this is addressed to dr. dickey, medpac proposed, that's the medicare payment advisory commission, proposed increasing primary care reimbursements and decreasing specialist reimbursements in medicare. many primary care providers

objected to decreasing specialty reimbursements. what would your advice be to policymakers on this issue? >> well, i think that to the degree that there's a single bucket of medicare dollars to be used to reimburse providers, physicians and advanced practice nurses and others, the reality probably is that some of the adjustment, if we want to attract more primary care is by adjusting it out of specialty payments. it may not be payment per service, it may be you reduce the numbers of specialty services which is part of that bending the cost curve many of us think will occur. so i'll get paid just as much r every coronary artery bypass i do, maybe i don't need to do as many of them if i follow evidence-based information.

obviously, i would assume those primary care physicians who don't want to take a pay increase off the backs of their colleagues, assume that somebody will put additional dollars into the bucket and specialists continue to get paid at the rates they are and we'll raise the tide and if that's an option, we'll all go for that. none of usant to be divisive within our peer groups. i don't think that's an option. i think we need to talk about the fact that the money that's in the system needs to actually either go to providing more care or somehow bend it so there's less money in the system suggest that we're going to have to take the dollars that are there and spread them around differently than we have. so it's nice that you want to take care of your colleagues, but i think the data says we need more primary care. >> ok. here's one that goes back to something that several of you have referenced, that is the

importance of preventive care. the questioner states, 37 states currently require insurers to provide prostate cancer screening as a benefit. but then we'll lose that benefit in currently debated health bills because they are not recommended by the u.s. preventive services task force. how can we ensure access to these important measures? if i can add a second half of that question, how do you judge what's an important measure if you don't take the word of the preventive services task force? is there some higher authority? >> let me reference the comparative effectiveness research that is addressed in the bills and has had a fair amount -- fair amount of conversation. about half of what we do in medicine today has pretty good research that says, this makes

a difference, or it doesn't make a difference. and what's -- what the bills have attempted to do is say, for that 50% that we have pretty good data, we ought to practice based on what the data sells -- tells us is good practice. for that 50% for which we do not have good data, we ought to be spending some of our research dollars to collect the data. one way to do that would be to say for the 50% we don't have data, if blue cross is going to pay for it for you, you should be enrolled in a study so that three years or five years or seven years from now we'll be able to give you data that says it either helps to get this care or it doesn't help. and so we could then begin to say, at least for insurance purposes, for which a third party is going to pay for your care, we will pay for those things that appear to make a difference in your longevity, in your quality of life, in the

timeliness of your recuperation, and then if you want to by those -- buy those things out of pocket for which there isn't good evidence but which either your physician or someone has convinced you you probably want to have it anyway, that's fine. you can always write a check for that. you just can't ask your insurance company to pay for it. but if we don't have the data, as we don't have for about half or a little more than half of what we already do, we have to find a way to collect the data and -- so we'll know where to put those things. is that a fair description of comparative effectiveness? >> and just to say about the specific case of prostate cancer, it sounds like a slam dunk. you want a test that tells you you have it, you want to know sooner rather than later. it's not that simple. prostate cancer grows very, very, very slowly. the odds are in many individuals that they will die

of something else, not the 3r0s tate cancer they have. we are only now beginning to discern which prostate cancers will grow fast and which will grow slowly. several years ago, a study was done of young men who died in vietnam and a lot of them had the early stages of prostate cancer. they weren't dead they weren't going to die of prostate cancer, they were probably going to die of something else. you have to say, does the screening test show what i think it does? does it show i have prostate cancer or not, not me obviously, but a man. then what's the intervention have? does it kill the -- does the intervention kill the person? does it require excess surgery? does it make me impotent when it didn't need to make my impotent because i could have gone to a different surgeon or

could have undertaken watchful waiting. once those things get done to people, you find out what they die of. you have to follow them and see if they die of prostate cancer or of something else. it's not clear that prostate cancer screening is always a slam dunk. it is clear that some people get treatment that they don't need and die of treatment that they didn't need for a disease that wasn't going to kill them. so as nancy says, until we understand all of this, it really -- it comes down to, are you going to recommend we take our precious health care resources and spend money on them, or are we going to spend money on things we have some evidence, while we gather evidence to figure out whether we should be doing these other things or not. >> there was an article in the -- i'm sorry, i'm not sure of the source, there was an article about british health care coverage and my legal

counsel for my academic health center came in and thought he was going to start a fight, i think, because he said, the brits have put a dollar figure on it. they decided if the cancer treatment costs more than, i'll get the numbers wrong, i apologize, but more than $20,000 and doesn't extend your life by at least 90 days, they're not going to pay for the care. so they began to say, we'll spend this much money for this much longevity. and i said, you know, i'm not sure that's all bad. we have treatment interventions that cost tens of thousands of dollars that we can't demonstrate extend your life at all and being a cancer survivor, i can tell you some of those treatments might make whatever extension of life you get almost not worth it. fortunately for me, i'm hopefully cured, but -- so we are going to have to start asking difficult questions about which interventions we

do, whether we do interventions for some groups and not others because different groups of people respond differently, but we should do it based on science. on having collected information from an adequate supply of people that we can then sit down with patients one-on-one and give them information in which to make intelligent choices. to do that, we'll probably move a lot of things we probably think of as routine care today into experimental models where we begin to collect this information. and there will be those who immediately scream, you're rationing care. but the reality is that if we're giving you care that costs you, or more likely someone else money and doesn't improve your life, then we probably ought to save those dollars for something that could make a difference in your life or somebody else's. it's going to be a tough time, i think, as we begin to explain to people that this thing we think of as great science often doesn't have much science at all behind it.

. this demonstrates the high quality of the conversation that we have been having. let me ask you if it allows some of those -- let me ask you to fill out some of those of violation forms. i like to think that johnson and johnson company for helping this. thank you for staying with this not an controversy year-old bundle of issues that a lot and a number of places, and join me in thanking this panel for very thoughtful discussion. thank you very much. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2009]